Prognosis

In those cases not due to severe lacerations of the perineum, tumors, ascites or absolute loss of tone, early relief and a possible ultimate cure are to be expected. A great deal has been done for some very unpromising cases.

Treatment

Prophylaxis is an important part of the treatment of prolapsus. Childbirth and its incidents cause most cases. Care at this time to prevent lacerations, or to see that they are promptly repaired when they do occur, is imperative. The period of involution should be closely observed to see that the uterus and all the tissues involved in pregnancy and parturition return to their normal condition. Severe physical exertion of any nature should be avoided for some time after delivery. All other contributing causes should be located and removed.

The immediate indication is for replacement. All the complicating conditions, ulceration, congestion or inflammation, yield more quickly and readily after replacement is effected. Replacement is ordinarily easiest performed in the knee-chest posture. (Fig. 40.) The bladder and intestines should be emptied. The patient may occupy the knee-chest position fifteen or twenty minutes before replacement is attempted. This allows the intestines to gravitate away from the pelvis and in some degree relieves congestion also. At times it may be advisable to put the patient to bed with her hips elevated for several hours, or longer, to free the pelvis of intestines and make replacement easier.

Fig. 40. Knee-chest Posture.

If the prolapse is not complete, pressure may be applied to the cervix and the uterus firmly but gently lifted in the direction of the inferior strait of the pelvis. The pressure should be steady, but slow and deliberate, taking fifteen or twenty minutes, if necessary, in reducing the displacement. Less time may be necessary in minor degrees of displacement, but the procedure is the same. After replacement a sweeping movement should be made with two fingers in the vagina, beginning at the median line or the anterior wall of the vagina and passing out on each side. This reduces the congestion in the vaginal walls as well as in the tissues between the layers of the broad ligaments.

In cases of complete prolapse, if the tumor is large and the vaginal walls thickened it must be replaced by beginning near its base and replacing that part of the inverted vagina that is nearest the vulva. As the vaginal walls are replaced, gentle and increasing pressure is made upon the uterus to compress it, and at the same time force it upward and backward in the direction of the sacral curve.

The uterus passes back into the pelvis in a position of retro-displacement. Replacement is not completed until by bimanual technic is it brought into its normal anteposition.

Occasionally in cases of long standing the formation of adhesions between the fundus and some adjacent organ or tissue, or great hypertrophy of the vaginal walls, may prevent replacement. Means for retaining the uterus in position are discussed in Chapter VIII (Tampons).

In the cases of "settling" relief of the congestion and reduction in the size of the uterus are necessary. Direct treatment to the organ itself as is described under the treatment of Endometritis will accomplish this result.

The treatment recommended by Dr. Still in "The Philosophy and Mechanical Principles of Osteopathy" is particularly applicable to these cases. He says, "We recommend placing the patient in the knee-and-chest position, with the chest for ease and comfort resting on a pillow, allowing the chin to hang over the head end to the table. Pass the right hand across the body in the lumber region and under the abdomen to the right iliac fossa. Then place the right hand flat upon the bowels from the pelvis, with the left hand pressing gently on that part of the abdomen. Be slow and gentle in all movements, for fear of bruising the caecum, ileo-caecal valve and the mesentery of that region. Make a gentle, strong pressure upward toward the ribs with the ascending colon. Follow across the abdomen from right to left, in order to straighten up the transverse colon to its normal position. Then lay the hand back toward the symphysis and gently press the sigmoid division toward the stomach, with a view to pulling that division of the colon and small intestines out of the pelvis. Then, with both hands gently and firmly pressed upon the anterior region of the abdomen come up toward the stomach with this gliding motion, with a view of straightening the bowels, from the caecum to the transverse, the descending and sigmoid division to the rectum. Also adjust the mesen tery in all its attachments both to the large and small intestines, and give freedom to the ileo-caecal valve, that the softening fluids may pass without delay into and through the colon. By so doing, we set at liberty and give freedom to the blood and nerve supply of the uterus, ovaries and Fallopian tubes. We also take all pressure off the nerves which govern the uterus and venous motion of blood from the pelvis and through the whole uterine system of blood, nerves and lymphatics."

Exercises to regain the tone of the abdominal, thoracic and pelvic muscles are necessary. The knee-chest posture for from three to five minutes should precede the exercises and should be assumed particularly on retiring at night and before a mid-day rest of an hour or more in bed.

For a full discussion of the necessary exercises the reader is referred to "The Therapeutics of Activity" by Dr. Andrew A. Gour. I often prescribe four simple exercises which I call the "fundamental four." These can be quickly demonstrated to the patient, are easily remembered, are effective if persistently followed, and are more likely to be carried cut than a more elaborate system.

1. Assume the knee-chest position for three to five minutes. Then lie on the back with knees flexed, hands back of head. Inhale deeply as knees are pressed forcibly to the right as far as possible, rotating pelvis in that direction, but keeping shoulders flat. Exhale as the knees are brought back to the median line. Inhale as they are carried to the left as far as possible and exhale again as they are returned to the median line. Repeat ten or twelve times to begin with. (Fig. 41.)

2. Lie on back, hands by sides. Inhale and reach as far upward and to the right with the right hand as possible and at the same time reach as far downward and to the left with the right foot as possible. Exhale as return to beginning position. Inhale and repeat with left hand and foot. Repeat ten to twelve times. (Fig. 42.)

3. Lie on back, hands back of head. Keep knees straight. Inhale as both feet are raised to a right angle with body or higher if possible. Exhale as they are lowered to beginning of this position. If this exercise is found too heavy begin by raising only one foot. Repeat five or six times to begin with. (Fig. 43.)

4. Lie face downward, hands on small of back. Inhale and raise head and shoulders as high as possible. Exhale as return to beginning of this position. Repeat six or eight times to begin with. (Fig. 44.)

Fig. 41. Exercises To Regain The Tone Of The Abdominal, Thoracic And Pelvic Muscles

Fig. 42.

Fig. 43.

Fig. 44.

These are essentially "mat" exercises, and restore tone and activity to the muscles of the thorax and abdomen, so fundamental to the maintenance of position and circulation of the pelvic and abdominal viscera.

Particular attention must be given to spinal innervation.